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Gynecological Oncology
Uterine Cancer now not recommended for women with low-risk stage I endometrial
Screening is not necessary for endometrial cancer; although common, the cancer.
28
Given that survival is no different between patients who receive
disease has a classic presentation (bleeding) and good prognosis with prophylactic brachytherapy and those who receive radiotherapy for local
effective treatment (surgery). Although screening with ultrasound for recurrence, some centers favor the latter, although, as it is minimally
thickened endometrial stripe has been advocated for patients who are on morbid, adjuvant brachytherapy remains popular in the US.
29
tamoxifen and are at an increased risk for endometrial cancer, there is no
Screening in the Broadest Sense
Screening for important symptoms that affect quality of life for patients
These important mechanistic pathways
living with cancer has a role. Clinicians should screen for depression, which
is common: ask the patient about her mood over the past few weeks, what
may unlock the identity of early
she enjoys, and how she feels about the future. Treatment can be simple
detection biomarkers, as well as
and inexpensive. Major depression, which occurs in 15% of ovarian cancer
patients,
30
causes distress that is prevalent enough for the National
identifying therapeutic targets.
Comprehensive Cancer Network (NCCN) to advocate its evaluation as the
sixth vital sign in patients with cancer.
31
Furthermore, a ‘collaborative care’
proactive team delivering optimal supportive and pharmacological
clear survival advantage over clinical surveillance for post-menopausal management has been shown to increase the resolution of symptoms by
bleeding, and the role of ultrasound may be limited to ‘screening’ prior to 60% in primary care patients,
32
and to double recovery from depression in
commencing tamoxifen to identify pre-existing benign lesions.
25
In the women with breast cancer or cervical cancer.
33
other group at a higher than average risk for endometrial cancer, subjects
with Lynch II syndrome <50 years of age with a significant family history (at Screening Driving Serendipity
least two first-degree relatives with one <50 years of age with colorectal or One of the most important outcomes of the huge global investment in
endometrial cancer), prophylactic hysterectomy and bilateral salpingo- research on the pathogenesis of cancer has been the discovery of new
oophorectomy prevents 100% of uterine cancers and is strongly advocated pathways, which may lead to markers that are useful in the early detection
over watchful waiting.
26
of disease. These important mechanistic pathways may unlock the
identity of early detection biomarkers, as well as identifying therapeutic
Sometimes endometrial cancer is diagnosed after a Pap smear showing targets. Although we may keenly feel the frustration with the decades
atypical cells of undetermined significance (ASCUS). Although the Pap required to complete definitive ovarian cancer screening trials and
smear is not a reliable or necessary screening method for endometrial determine whether screening has an effect on survival, such trials have
cancer, it tends to be abnormal in women with endometrial carcinoma galvanized the research community to utilize the latest proteomic and
and associated with a worse stage.
27
The Pap smear is commonly used to genomic methods to identify better early detection biomarkers as
‘screen’ for local recurrence during surveillance. Adjuvant radiotherapy is promising approaches to improve screening in the future. ■
1. Wilson J, Jungner G, Principles and Practice of Screening for 14. Koutsky LA, Ault KA, Wheeler CM, et al., A controlled trial of a increase susceptibility to human invasive cervical cancer, Cancer
Disease, WHO Chronicle, 1968;22:473. human papillomavirus type 16 vaccine, N Engl J Med, 2002; Res, 2007;67:11202–8.
2. Croce CM, Oncogenes and cancer, N Engl J Med, 2008;358: 347:1645–51. 25. Neven P, De Muylder X, Van Belle Y,et al., Longitudinal
502–11. 15. Harper DM, Franco EL, Wheeler C, et al. Efficacy of a bivalent L1 hysteroscopic follow-up during tamoxifen treatment, Lancet,
3. www.cancer.gov/newscenter/cervicalcancer virus-like particle vaccine in prevention of infection with human 1998;351:36.
4. www.researchandmarkets.com/product/f8c754/biomarkers_2008 papillomavirus types 16 and 18 in young women: a randomised 26. Schmeler KM, Lynch HT, Chen LM, et al., Prophylactic surgery to
5. Damasus-Awatai G, Freeman-Wang T, Human papilloma virus and controlled trial, Lancet, 2004;364:1757–65. reduce the risk of gynecologic cancers in the Lynch syndrome,
cervical screening, Curr Opin Obstet Gynecol, 2003;15:473–7. 16. Jandorf L, Fatone A, Borker PV, et al., Creating alliances to N Engl J Med, 2006;354:261–9.
6. Jemal A, Siegel R, Ward E, et al., Cancer statistics, 2006, CA improve cancer prevention and detection among urban medically 27. Demirkiran F, Arvas M, Erkun E, et al., The prognostic significance
Cancer J Clin, 2006;56:106–30. underserved minority groups. The East Harlem Partnership for of cervico-vaginal cytology in endometrial cancer, Eur J Gynaecol
7. Castellsague X, Bosch FX, Munoz N, et al., Male circumcision, Cancer Awareness, Cancer, 2006;107:2043–51. Oncol, 1995;16:403–9.
penile human papillomavirus infection, and cervical cancer in 17. Cannistra SA, Cancer of the ovary, N Engl J Med, 2004;351: 28. Lukka H, Chambers A, Fyles A, et al., Adjuvant radiotherapy in
female partners, N Engl J Med, 2002;346:1105–12. 2519–29. women with stage I endometrial cancer: a systematic review,
8. www.cancer.org/docroot/STT/stt_0_2006.asp? 18. Moore RG, Bast RC Jr, How do you distinguish a malignant pelvic Gynecol Oncol, 2006;102:361–8.
sitearea=STT&level=1 mass from a benign pelvic mass?, J Clin Oncol, 2007;25:4159–61. 29. Creutzberg CL, van Putten WL, Koper PC, et al., Survival after
9. Walboomers JM, Jacobs MV, Manos MM, et al., Human 19. Kauff ND, Satagopan JM, Robson ME, et al., Risk-reducing relapse in patients with endometrial cancer: results from a
papillomavirus is a necessary cause of invasive cervical cancer salpingo-oophorectomy in women with a BRCA1 or BRCA2 randomized trial, Gynecol Oncol, 2003;89:201–9.
worldwide, J Pathol, 1999;189:12–9. mutation, N Engl J Med, 2002;346:1609–15. 30. Bodurka-Bevers D, Basen-Engquist K, Carmack CL, et al.,
10. Munoz N, Bosch FX, de Sanjose S, et al., Epidemiological 20. Bast RC Jr, Klug TL, St John E, et al., A radioimmunoassay using a Depression, anxiety, and quality of life in patients with epithelial
classification of human papillomavirus types associated with monoclonal antibody to monitor the course of epithelial ovarian ovarian cancer, Gynecol Oncol, 2000;78:302–8.
cervical cancer, N Engl J Med, 2003;348:518–27. cancer, N Engl J Med, 1983;309:883–7. 31. Holland JC, Bultz BD, The NCCN guideline for distress
11. Castellsague X, Diaz M, de Sanjose S, et al., Worldwide human 21. Goff BA, Mandel LS, Drescher CW, et al., Development of an management: a case for making distress the sixth vital sign,
papillomavirus etiology of cervical adenocarcinoma and its ovarian cancer symptom index: possibilities for earlier detection, J Natl Compr Canc Netw, 2007;5:3–7.
cofactors: implications for screening and prevention, J Natl Cancer Cancer, 2007;109:221–7. 32. Rush AJ, STAR*D: what have we learned?, Am J Psychiatry,
Inst, 2006;98:303–15. 22. Jacobs IJ, Skates SJ, MacDonald N, et al., Screening for ovarian 2007;164:201–4.
12. Melnikow J, Nuovo J, Willan AR, et al., Natural history of cervical cancer: a pilot randomised controlled trial, Lancet, 1999;353: 33. Dwight-Johnson M, Ell K, Lee PJ, Can collaborative care address
squamous intraepithelial lesions: a meta-analysis, Obstet Gynecol, 1207–10. the needs of low-income Latinas with comorbid depression and
1998;92:727–35. 23. Visintin I, Feng Z, Longton G, et al., Diagnostic markers for early cancer?, Results from a randomized pilot study, Psychosomatics,
13. Erbelding EJ, Zenilman JM, Toward better control of sexually detection of ovarian cancer, Clin Cancer Res, 2008;14:1065–72. 2005;46:224–32.
transmitted diseases, N Engl J Med, 2005;352:720–21. 24. Zhang Z, Borecki I, Nguyen L, et al., CD83 gene polymorphisms
96 US OBSTETRICS & GYNECOLOGY
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